Transfer to the Ward
Leaving intensive care should be a time for celebration the patient is getting better and is now well enough to no longer need the highest levels of care. However, this can be a very difficult time for patients and families particularly if the admission to intensive care has been long. No matter how much preparation has been done, patients will find a dramatic difference in the level of care between the critical care area and general wards and sometimes report of feeling abandoned. Anxiety and depression are common after discharge from the unit and patients may also have sleep problems.
There will be fewer nurses and less equipment on the ward. It might seem a bit of a shock going to an environment where there is less attention, and it is natural to worry that there is less care. However, be reassured that this is because the patient is getting better and needs less support.
During a patient's stay in the ICU, he or she will have lost weight and muscle tone. Joints may also be stiff due to the long time spent in bed. and there may some loss of sensitivity in the fingers and other small joints. These problems can be quite distressing, but as the patient becomes more active, muscle weakness and joint stiffness will improve as part of the recovery process.
Even though they are getting better, the patient may feel anxious and depressed about the effects of being critically ill. This is an understandable reaction and you can help by encouraging them to talk about their feelings.
The key issues a patient faces are:
The change in environment
Although intensive care can be a difficult place to be, like any situation you get used to it, and it is a big change going to a ward. The daily routines are different, the staff are different, the sounds are different. The other patients are likely to be well enough to talk to you, but this is very different from intensive care. Some patients on the ward may be confused or noisy and this can be very disturbing. Most of the beeps and noises from the machines will have stopped, but these beeps and alarms will often have become familiar and their absence can be just as worrying for some patients.
The change in the patient
The process of recovery from severe illness is not easy. Going back to the ward often means a patient is becoming able to do a lot more themselves, and this can be very hard work and tiring, particularly if a patient is adapting to new disabilities or injuries. Learning to eat and swallow normally again, to go to the toilet normally are far from trivial, and can be very embarrassing.
The change in the staffing
Intensive care usually has one nurse per patient, on a ward there may only be two or three nurses for the whole ward, especially at night time and not all of them will be trained to the same level as the intensive care nurses. Patients have to learn to use call bells to get attention and there can be delays in someone responding. The family have to appreciate that the nurse isn't just looking after one patient and can't give the detailed ongoing explanation of each change and what is happening that the intensive care nurses could. As a result patients and families sometimes feel neglected or deserted. The patient is being looked after, it's just that the change in the level of care is dramatic.
The medical team
The team looking after the patient will often be known to you but they may not have been involved in detail for several days and they will have a thorough handover from the intensive care staff. It will still take time for them to get to grips with all the detail, again they will often have many more patients to look after than the doctors on the intensive care unit.
How do the teams decide when a patient is fit to leave intensive care?
These decisions can be very difficult. Clearly if there is a specific reason why a patient needed intensive care and that has been fixed and there are no ongoing problems then it is straightforward. However in some cases patients are on intensive care for a long time and have multiple problems which only get better slowly and there is a not a specific point at which everything is fixed. It wouldn't be good to keep patients on intensive care longer than they need to be there as not only are they exposed to greater risks of complications and the intensive care unit isn't the best environment to start all the rehabilitation needed and to start interacting with other people again and the process of returning to normal.
Sometimes there will be a stage when although a patient is still very unwell there is nothing that can be done in intensive care that will make a difference, and these patients will return to the ward, but it must be recognised that they are still at high risk of complications and deteriorating and if this happens they will be readmitted if there is something that can be done to help.
Patients sometimes have to transfer to another team when they leave intensive care, for example if they are getting better but the kidneys are still not working they will go to the renal ward where they can continue having dialysis until their kidneys recover.
The decision to leave intensive care ultimately rests with the intensive care consultant, but these decisions are made in close consultation with the nurses and doctors on the intensive care team and the specialist teams involved. There is a detailed handover between the intensive care nurses and the ward nurses and between the medical teams. There are also detailed and thorough "summaries" written by the intensive care doctors and nurses.
Many hospitals now have an outreach team of intensive care trained nurses and doctors who follow up intensive care patients on the ward and address any specific issues they can help with. This ensures that there is as seamless a transfer of care as possible.